Suture rundown tool and cutter system

ABSTRACT

A suture throw holder, rundown tool and cutting system for running one or more throws formed in two lengths of suture extending from a surgical site down to the surgical site so as to form a knot at the surgical site and for blindly cutting the suture ends adjacent the knot. The system comprises a support mechanism for releasably supporting a plurality of throws in a predetermined arrangement adjacent a surgical site, and a tool for removing throws from the support mechanism, running the throws down the lengths of the suture to the surgical site, and blindly cutting the suture ends at substantially equal lengths every time adjacent a knot formed by the throws at the surgical site.

CROSS-REFERENCE TO RELATED APPLICATIONS

This is a division of U.S. application Ser. No. 07/544,409 filed Jun.27, 1990 U.S. Pat. No. 5,084,058, for SUTURE RUNDOWN TOOL AND CUTTERSYSTEM, which was itself a continuation-in-part of U.S. application Ser.No. 07/514,179 filed Apr. 25, 1990 U.S. Pat. No. 5,087,263, for SUTURETHROW HOLDER AND RUNDOWN SYSTEM.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to surgical instruments for securingsutures in tissue and, more particularly, is directed to instruments forforming a plurality of suture throws at a location remote from asurgical site, running the throws serially down the lengths of suture soas to form a knot at the surgical site, and cutting the suture endsadjacent the knot.

2. Description of the Prior Art

In both closed (e.g. arthroscopic) and open surgeries, it is frequentlynecessary to form a knot at a surgical site using two lengths of sutureemanating from the surgical site, wherein the two lengths of suture mustbe manipulated with respect to one another at a location remote from thesurgical site.

With one known procedure, a "taut-line hitch" knot is formed in theloose ends of the suture at a location remote from the surgical sitefrom which the suture ends emanate, and then the knot is run down thesuture ends to the surgical site by pulling with a sawing motion on theappropriate suture ends. A significant drawback to this procedure isthat as the appropriate suture end is pulled through the tissue in whichthe suture is implanted so as to run the knot down to the surgical site,the sawing motion imparted to the suture ends causes the latter to tendto cut and abrade the tissue.

An alternative procedure consists of forming a throw in the suture at alocation remote from the surgical site from which the suture endsemanate, running the throw down the length of suture to the surgicalsite, forming a second throw in the suture at a location remote from thesurgical site, running that throw down the length of suture to thesurgical site so that it sits atop the first throw, and thereafterrepeating the foregoing process as many times as necessary so as to formthe desired knot at the surgical site. As used herein, a "turn" consistsof two ends of suture which are looped over one another one or moretimes, a "throw" consists of one or more turns, and a "knot" consists oftwo or more throws laid on top of one another and tightened so as tolock the two strands of suture relative to one another. Once the knothas been made, the suture ends are cut near the knot be means of longsurgical scissors.

Arthrex Arthroscopy Instruments, Inc. of Black Rock, Connecticutmanufactures several tools for running a suture throw down suture endsto a surgical site from a location remote from the surgical site. Onesuch tool is identified as the Arthrex Arthroscopy Knot Pusher (ModelNo. AR-1310). This knot pusher comprises an elongate shaft having an endportion which is inclined slightly with respect to the long axis of theshaft. The end portion includes a bore extending therethrough. After athrow is formed in the suture ends at a location remote from thesurgical site from which the suture ends emanate, one of the ends isthreaded through the bore in the end portion of the knot pusher. Thenthe tool is run down the length of that suture end, while maintainingappropriate tension on the suture ends, so as to push the throw towardthe surgical site. Once the first throw has been run down the suturelengths to the surgical site, another throw may be formed in the sutureends at a location remote from the surgical site and then run down thesuture ends to the surgical site so that it sits atop the first throw.This procedure may be repeated as many times as desired so as to form aknot at the surgical site.

Arthrex Arthroscopy Instruments, Inc. manufactures another knot pushertool identified as Model No. AR-1311. This tool comprises an elongateshaft having a rounded front end, and a pair of holes extending in fromthe sides of the shaft at an angle and terminating at the front end ofthe shaft. To use the Model No. AR-1311 tool, a throw is formed in thesuture ends emanating from the surgical site. Then, each of the freeends of the suture extending away from the throw is threaded into acorresponding respective one of the holes in the front end of the tooland caused to pass out the end of that hole intersecting the side of thetool. Next, the surgeon grasps the suture ends extending out of theholes in the sides of the tool and applies tension to the suture ends.Thereafter, while maintaining this tensioning of the suture ends, thesurgeon urges the tool toward the surgical site by pushing against therear end of the tool, typically with his or her stomach, thereby causingthe tool to run the throw down the suture ends to the surgical site. Asthe throw is run down to the surgical site, successive portions of thesuture ends emanating from the surgical site pass through the holes inthe rundown tool. Finally, the rundown tool is extracted from thesurgical site, whereby the suture ends pass back through, and ultimatelyare removed from the holes in the rundown tool. Subsequent throws arerun down to the surgical site following this procedure. The suture iscut after the knot has been completed, the free ends of the suture arecut near the knot using scissors.

Yet another Arthrex rundown tool is illustrated, although not described,on page 7 of a brochure published by Arthrex Arthroscopy Instruments,Inc. entitled "The Arthrex Grasping Stitcher System". This rundown toolcomprises an elongate shaft which apparently has a rounded or convexV-shaped front end, and a pair of axially-extending, diametricallyopposed grooves which terminate at the front end of the tool. A ringsurrounds and engages the front end of the shaft, whereby the groovesare surrounded by the ring. This Arthrex tool apparently functionssubstantially identically to the Arthrex tool Model No. AR-1310described above, except that each of the suture ends is positioned in arespective one of the elongate grooves and is passed underneath thesurrounding ring, rather than being threaded in the holes at the frontend of the Arthrex tool Model No. AR-1310. As in the case of thepreviously mentioned run-down tools, a pair of scissors is used to cutthe suture ends at the knot.

SUMMARY OF THE INVENTION

An object of the present invention is to provide a suture throw holderrundown tool and cutter system in which the throw holder and rundownsystem permits a plurality of throws, formed in two lengths of sutureemanating from a surgical site, to be prelaced and held in a locationremote from the surgical site, and then to be quickly and easily rundown the suture ends to the surgical site so as to form a knot at thesurgical site, and in which the cutter permits the suture ends to beblindly cut to substantially the same length every time adjacent theknot.

Another object of the present invention is to provide a suture holder,rundown tool and cutter system in which the suture throw holder andrundown system permits a plurality of throws to be tied in suture endswhich extend away from a surgical site and to be supported in a locationremote from the surgical site, whereby the throws can be run down thesuture ends one after another to the surgical site without the need topause and tie a new throw after a preceding throw is run down the sutureends to the surgical site and the cutter is guided in a bore formed inthe suture rundown system to blindly cut the suture ends tosubstantially the same length every time adjacent the knot.

Yet another object of the present invention is to provide a suture throwholder rundown tool with a cutter which permits a multiple-turn throw tobe run down the suture ends extending from a surgical site to form aknot and permits the suture ends to be blindly cut to substantially thesame length every time adjacent the knot.

Still another object of the present invention is to provide a suturethrow holder, rundown tool and cutter system which automaticallymaintains substantially equal tension on the suture ends emanating froma surgical site while throws are being run down the suture ends to thesurgical site and permits the suture ends to be blindly cut tosubstantially the same length every time adjacent the knot withoutinjury to adjacent tissue.

These and other objects are achieved by a suture throw holder, rundowntool and cutter system comprising (1) a support mechanism for releasablysupporting, adjacent a surgical site, a plurality of suture throwsformed from suture ends extending from the surgical site, (2) a rundowntool for removing the throws from the support mechanism and for runningthe throws down the suture ends to the surgical site to form a knot and(3) a cutter for blindly cutting the suture ends to substantially samelength every time adjacent the knot.

The support mechanism comprises a top surface to which a plurality ofgroups of four pegs are attached. The pegs are arranged so as to permit(a) the lengths of suture extending from the surgical site to beinterwoven between the pegs, and (b) throws formed using the interwovenportions of the suture to be releasably supported adjacent each of thegroups of pegs so as to extend away from the leading edge of the supportmechanism in a linear array. Each group of four pegs consists of twosubgroups of two pegs each, two leading and two trailing; the sutureends are woven around the outside of the first subgroup of two pegs andaround the inside of the second subgroup of two pegs, with the throwsbeing captivated about the two subgroups of pegs. The support mechanismalso includes two pairs of legs for supporting the top surface in apredetermined orientation relative to the surgical site.

The suture throw rundown tool comprises an elongate shaft having adepression in the front end thereof. The shaft also includes a pair ofdiametrically opposed elongate grooves formed in the side walls of theshaft which intersect and extend rearwardly from the front end of theshaft along a portion of the axis of the shaft to form an internalcavity. A transverse slot intersects the grooves and communicates withthe cavity the slot being sized to receive the suture. The shaft isformed with a central bore that extends the entire length of the tool,the bore intersecting the cavity.

The cutter comprises an elongate shaft having a blade at a front end anda handle at a back end. The cutter shaft is sized and shaped to beslidably received in the central bore formed in the tool shaft. Thecentral core defines a guideway for the cutter shaft.

In use, a first throw is formed on the support mechanism using the twoends of suture extending from the surgical site. The first throw isreleasably secured to the group of pegs closest to the front end of thesupport mechanism. Subsequent throws are formed using the remainingportions of the suture ends and are releasably secured to correspondingrespective groups of pegs. Then, the lengths of suture leading from thesurgical site to the first throw are detached from the two leading pegsof the first group around which they are wrapped by appropriatelymanipulating the support mechanism. Next, the first throw is engaged bythe throw rundown tool by inserting the throw in the V-shaped groove inthe front of the shaft of the rundown tool. Then the shaft, with throwcaptivated therein, is urged toward the surgical site, pushing the throwdown the suture ends ahead of the rundown tool, until the throw ispositioned adjacent the tissue surface from which the lengths of sutureemanate. Subsequent throws are run down to the surgical site in thesequence they are supported on the support mechanism following theforegoing procedure, whereby a knot is formed in the suture at thesurgical site. The cutter is urged downwardly in the central bore andthe cutter blade severs the suture ends substantially equally adjacentthe knot.

Still other objects and features of the invention will in part beobvious and will in part appear hereinafter. The invention accordinglycomprises the apparatus possessing the construction, combination ofelements, and arrangement of parts which are exemplified in thefollowing detailed disclosure. The scope of the present invention willbe indicated in the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

For a fuller understanding of the nature and objects of the presentinvention, reference should be made to the following detaileddescription taken in connection with the accompanying drawings wherein:

FIG. 1 is a side elevation view of the suture throw support device;

FIG. 2 is a plan view of the throw rundown tool showing the V-shapedgroove in the front of the tool in profile;

FIG. 3 is a rear elevation view of the suture throw support device, withthe legs of the device being shown in the open position in solid viewand in the closed position in phantom view;

FIG. 4 is a plan view of the suture throw support device, with sutureattached;

FIG. 5 is a side elevation view, partially in section, showing a suturedeployed in a typical surgical site;

FIG. 6 is a front elevation view showing the suture throw support deviceresting on the surface of tissue adjacent a surgical site, which isshown in cross section;

FIG. 7 is an enlarged plan view of the front portion of the suture throwsupport device shown in FIG. 4;

FIG. 8 is a perspective view showing lengths of suture extending fromthe surgical site to the suture throw support device, with the front endof the rundown tool set to engage the leading throw on the supportdevice;

FIG. 9 is a perspective view showing the suture throw support devicebeing manipulated to release the suture from the first two pegs on thesupport device;

FIG. 10 is a front elevation view showing the suture throw supportdevice elevated slightly above the opening in tissue leading to thesurgical site and the leading throw captivated in the front groove ofthe rundown tool;

FIG. 11 is similar to FIG. 10, except that the front end of the rundowntool, and the throw captivated therein, has been moved to a positionadjacent the target tissue at the surgical site;

FIG. 11a is similar to FIG. 11, except that the suture device has beenmanipulated to release the suture from the two leading pegs of thesecond group of pegs;

FIG. 12 is similar to FIG. 11, except that the second throw supported onthe support device is captivated in the front groove in the supporttool;

FIG. 13 is similar to FIG. 12, except that the front end of the rundowntool, and the second throw captivated therein, has been positioned atthe surgical site directly above the first throw;

FIG. 14 is similar to FIG. 13, except that all of the throws supportedon the support device have been run down to the surgical site and therundown tool has been removed from operative association with thesupport device;

FIG. 15 is a perspective view of an alternative embodiment of the suturethrow device;

FIG. 16 is a plan view of an alternative embodiment of the throw rundowntool showing the V-shaped groove in the front of the tool in profile;

FIG. 17 is an enlarged cross-sectional view taken along line 17--17 inFIG. 16;

FIG. 18 is a side elevation view, taken in cross section, showing thefront end of another embodiment of the rundown tool;

FIG. 19 is a plan view of another embodiment of the suture throw holderof the present invention shown adjacent the opening to a surgical sitefrom which two suture ends emanate;

FIG. 20 is a perspective view of the holder shown in FIG. 19, with thesuture ends emanating from the surgical site being formed into asurgeon's knot;

FIG. 21 is a side elevation view of the holder and suture ends shown inFIG. 20;

FIG. 22 is similar to FIG. 20, except that the suture portions extendingaway from the surgeon's knot have been wrapped around the front pegs ofthe holder, formed into a single-turn throw, wrapped around the rearpegs of the holder, and anchored to the clamp of the holder;

FIG. 23 is a side elevation view of the holder and suture ends shown inFIG. 22;

FIG. 24 is similar to FIG. 22 except that a knot rundown tool has beenmoved into engagement with the surgeon's knot supported adjacent theholder;

FIG. 25 is a side elevation view of the holder, rundown tool, and sutureends shown in FIG. 24;

FIG. 26 is a plan view of another embodiment of the rundown tool of thepresent invention, with a portion of the handle of the tool being brokenaway to reveal the internal construction of the handle;

FIG. 27 is a perspective view of the front end of another embodiment ofthe rundown tool of the present invention; and

FIG. 28 is a side elevation view of the rundown tool shown in FIG. 27,with a surgeon's knot formed using the ends of suture emanating from asurgical site being positioned in the front groove of the rundown tool.

FIG. 29 is a perspective view in side elevation of the rundown tool andcutter system embodying the present invention;

FIG. 30 is a perspective view in side elevation, partly broken-away, ofthe rundown tool and cutter system shown in FIG. 29;

FIG. 31 is a side elevation in section of the rundown tool and cuttersystem shown in FIG. 29;

FIG. 32 is a side elevation of the cutter shown in FIG. 30;

FIG. 33 is a side elevation of the rundown tool and cutter system shownin FIG. 29 with a surgeon's knot being positioned in a front groovethereof, the ends of the suture exiting on opposite sides; and

FIG. 34 is a side elevation of the rundown tool and cutter system shownin FIG. 29 with a surgeon's knot being positioned in a front groovethereof, the ends of the suture existing on the same side.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

Referring first to FIGS. 1-4, there is shown is a suture throw holderand rundown system for releasably supporting a plurality of suturethrows formed using two loose ends of suture extending away from asurgical site and for successively running the throws down the lengthsof suture to the surgical site so as to form a knot in the suture endsadjacent the surface of the tissue at the surgical site. The suturethrow holder and rundown system of the present invention comprises asuture throw support device 20 and a rundown tool 100.

Support device 20 comprises an elongate frame 22 having a top surface24, a front surface 26, side surfaces 28 and 30 (FIGS. 1, 3 and 4), anda rear surface 32. The length of top surface 24 (as measured betweenfront surface 26 and rear surface 32) is preferably significantlygreater than its width (as measured between side surfaces 28 and 30). Inan exemplary embodiment of the present invention, top surface 24measures about 6" long and 2" wide.

Frame 22 includes an elongate groove 38 (FIGS. 1, 3 and 4) formed in topsurface 24. Groove 38 is positioned so that its long axis extendsparallel to the long axis of top surface 24 and so that it bisects thewidth of the top surface. Groove 38 is sized to receive a front portionof throw rundown tool 100, as discussed hereinafter.

Frame 22 also includes a cleat 40 attached to rear surface 32 (FIGS. 1,3 and 4). Cleat 40 includes a base 42 attached to rear surface 32, andan elongate member 44 attached to base 42. Base 42 is sized so that theelongate member 44 is elevated slightly above rear surface 32, therebypermitting lengths of suture to be wedged between rear surface 32 andthe bottom of elongate member 44, as discussed hereinafter.

Frame 22 additionally comprises a pair of feet 50 (FIGS. 1, 3 and 4)attached to the front end of the frame adjacent its front surface 26.Feet 50 project out from the side surfaces 28 and 30 of the frame, andthe bottom surfaces of the feet are inclined at about a 45° anglerelative to front surface 26, as seen in FIG. 1.

Frame 22 further includes a plurality of groups 52 (FIG. 4) of pegs forreleasably supporting suture throws on the frame. Each group 52comprises a pair of leading pegs 54 and a pair of trailing pegs 56. Pegs54 and 56 have a solid, elongate, preferably cylindrical configuration,although pegs of other cross-sectional configurations may also beemployed. In an exemplary embodiment, pegs 54 and 56 extend about 0.5"above the plane of surface 24. Each of the trailing pegs 56 includes anelongate finger 58, one end of which is attached to the top surface ofeach of the trailing pegs so as to extend toward front surface 26.

Pegs 54 are attached to top surface 24 so that they pitch outwardly andforwardly slightly, toward side surfaces 28 and 30, in the manner shownin FIG. 3. Pegs 56 are attached to top surface 24 so as to extendsubstantially perpendicular thereto, in the manner shown in FIG. 3.Additionally, pegs 54 lie along a leading plane which extendsperpendicular to both top surface 24 and the long axis of the topsurface, and pegs 56 lie along a trailing plane which extendsperpendicular to both top surface 24 and the long axis of the topsurface, with the leading plane (i.e., the plane of leading pegs 54)being positioned closer to front surface 26 than the trailing plane(i.e., the plane of trailing pegs 56). Leading pegs 54 are positionedadjacent side surfaces 28 and 30, while trailing pegs 56 are positionedinboard from the side surfaces, adjacent groove 38 (see FIGS. 3 and 4).In an exemplary embodiment of the present invention, leading pegs 54 arespaced apart about 1.75", trailing pegs 56 are spaced apart about 1",and the leading plane on which pegs 54 lie is spaced about 0.25" closerto front surface 26 than the corresponding trailing plane on which pegs56 lie.

Support device 20 additionally comprises a pair of legs 70 and 72 (FIGS.1 and 3) which are attached to the bottom of frame 22 adjacent its rearsurface 32. Legs 70 and 72 are pivotally mounted to frame 22 so as to bemovable between an open position (shown in solid view in FIG. 3) and aclosed position (shown in phantom view in FIG. 3). In the open positionlegs 70 and 72 extend outboard of side surfaces 28 and 30 in an invertedV-shaped configuration, while in the closed position legs 70 and 72 arepositioned inboard of side surfaces 28 and 30 in a parallel, pistol-gripconfiguration. A detent stop mechanism (not shown) is provided forreleasably securing legs 70 and 72 in an open position (shown in FIG.3). Legs 70 and 72 are sized and configured so that the user of suturethrow support device 20 can grasp the legs in his or her hands when thelegs 70 and 72 are positioned in their closed position, as discussedhereinafter. Additionally, legs 70 and 72 are sized and configured sothat when the support device 20 is positioned so that its front feet 50and its rear legs 70 and 72 rest on a surface adjacent a surgical site,with legs 70 and 72 in the open position, the support device will bemaintained in a predetermined orientation relative to the surgical site,as discussed hereinafter.

Referring next to FIG. 2, knot rundown tool 100 comprises an elongateshaft 102 and a handle 104 attached to the rear end of the shaft. Aconvex, V-shaped groove 106 is provided in the front end of the shaft.The base (i.e., bottom) 107 of groove 106 intersects the longitudinalaxis of shaft 102. Shaft 102 also includes a pair ofdiamatically-opposed elongate grooves 108, only one of which is shown inFIG. 1. The elongate grooves 108 intersect the base 107 of V-shapedgroove 106 and extend rearwardly from the latter, parallel to the axisof the shaft. Shaft 102 additionally comprises a pair ofdiametrically-opposed, V-shaped notches 110, only one of which is shownin FIG. 1. Notches 110 are formed in the front ends of elongate grooves108 so that the wide end of the notches intersects the base of V-shapednotch 106.

Operation of the suture throw holder and rundown system of the presentinvention will now be described.

Looking next at FIG. 5, there is shown a representative surgicalscenario in which the present invention might be used to maintain aplurality of suture throws, formed in two lengths of suture emanatingfrom an interior surgical site, at a location remote from the surgicalsite, and to run them serially down the lengths of suture so as to forma knot at the surgical site. More specifically, in the representativesurgical scenario depicted in FIG. 5, it might be desired to use asuture 200 to fasten an upper tissue piece 202 to a lower tissue piece204, where the tissue pieces 202 and 204 are positioned deep within abodily member, access being gained to the site via a hollow cannula 206positioned in surface tissue 208.

In such a circumstance, the suture 200 would first be emplaced in tissuepieces 202 and 204 using methods well known in the art, so that anintermediate portion of the suture is positioned at the surgical site asneeded, and the two suture ends 200A and 200B extend out through thehollow cannula's interior passageway 210 so that they reside outside thebody. The present invention provides a means for supporting a pluralityof throws formed using loose suture ends 200A and 200B adjacent themouth of cannula 206, at a position outside the body, and for runningthe throws serially down the suture ends to the top surface 212 of uppertissue piece 202, whereby a knot may be formed at top surface 212 so asto effect the desired attachment of tissue pieces 202 and 204 to oneanother.

It should of course, be appreciated that the surgical scenario depictedin FIG. 5 (and discussed in the following description of the operationof the present invention) is merely one of many different surgicalscenarios in which the present invention could be utilized, and isprovided solely by way of illustration and not of limitation. As will berecognized by persons skilled in the art, the present invention could beused in a wide variety of other surgical scenarios in which it isdesired to maintain a plurality of suture throws, formed in two lengthsof suture emanating from an interior surgical site, at a location remotefrom the surgical site, and to run them serially down the length ofsuture so as to form a knot at the surgical site.

Starting then with the surgical scenario depicted in FIG. 5, as a firststep of using the present invention, legs 70 and 72 of support device 20are spread apart to the open position, as illustrated in FIGS. 3 and 6.Then, support device 20 is positioned so that its feet 50 rest onsurface 214 of surface tissue 208 adjacent cannula 206 and its legs 70and 72 rest on surface 214 near cannula 206. Preferably, feet 50 arethen secured to surface 214 using surgical tape 216 (FIG. 6). Feet 50and legs 70 and 72 are sized and configured so that when support device20 rests on tissue surface 214, top surface 24 of the frame 22 isinclined at about a 45° angle relative to skin top surface 214.

Next, a plurality of throws (formed using loose suture ends 200A and200B) are releasably secured to pegs 54 and 56 of support device 20. Tobegin this process, suture ends 200A and 200B are wrapped around theouter surfaces of leading pegs 54 (FIG. 7) of the first group 52A ofpegs and are positioned under fingers 58 of trailing pegs 56. Then, afirst throw 232, preferably a double turn throw, is formed using thoseportions of ends 200A and 200B extending away from the pegs 54 (aroundwhich they are wrapped) toward rear surface 32 of support device 20.

Then, the portions of suture ends 200A and 200B extending from firstthrow 232 toward the second group 52B of pegs are wrapped around theinner surface of trailing pegs 56 of first group 52A, and are thenwrapped around the outer surface of leading pegs 54 of second group 52B.

In the unusual event that only one throw is to be supported on frame 22,the portions of suture ends 200A and 200B leading rearwardly away fromfirst throw 232 and around pegs 54 of second group 52B are tensioned andsecured to cleat 40 by wrapping the suture ends around cleat base 42 andwedging the portions between rear surface 32 and the bottom surface ofelongate member 44.

In the alternative (and more usual) event that multiple throws are to besupported on frame 22, the portions of suture ends 200A and 200Bextending rearwardly from leading pegs 54 of group 52B are positionedunder fingers 58 of trailing pegs 56 of group 52B, and a second throw234 is formed using these portions of the suture ends. Additional throwsare similarly formed as desired using suture ends 200A and 200B adjacentsuccessive ones of peg groups 52. After the last throw is formed, thesuture ends extending rearwardly from the last throw are tensioned andare secured to cleat 40, as discussed above, in the manner shown in FIG.6.

Thereafter, the user of the suture throw holder and rundown systemdetaches tape 216 so as to free support device 20 from skin surface 214,moves legs 70 and 72 of support device 20 to the closed position (FIG.3), and grips the legs in his or her hand 240 (FIG. 8). Then, the userelevates the support device slightly above surface 214 of surface tissue208 so as to nearly eliminate the slack in the portions of suture ends200A and 200B extending between surface 214 of upper tissue piece 208and leading pegs 54 of first group 52A (FIG. 8). Next, the user dips androtates support device 20 so as to disengage suture ends 200A and 200Bfrom leading pegs 54 of group 52A (FIG. 9).

Once this has been accomplished, the user grasps handle 104 of rundowntool 100 and manipulates the latter so that first throw 232 is receivedin V-shaped groove 106 in shaft 102, as shown in FIG. 10. Morespecifically, throw 232 is positioned in V-shaped groove 106 so that theends of suture portions 200A and 200B extending rearwardly away from thethrow are received in notches 110 and at least the front portions ofelongate grooves 108. See FIG. 10. Typically, tool 100 is inclined asthis is done so that its long axis forms an angle θ with top surface 24f frame 22 (FIG. 8). Preferably, angle θ is about 15°-30°. To receivethrow 232 in V-shaped groove 106, the bottom portion of the front end ofshaft 102 is typically inserted in groove 38 in top surface 24immediately behind the throw. The cross-sectional size and configurationof groove 38 is chosen so that this bottom portion of shaft 102 can beaccommodated in the groove. Notches 110 direct the trailing ends of thethrow residing in V-shaped groove 106 into elongate grooves 108.Elongate grooves 108 in shaft 102 are provided to ensure that theportions of suture ends 200A and 200B extending rearwardly from thethrow which is received in V-shaped groove 106 do not twist around thefront end of shaft 102.

Next, while holding support device 20 so as to maintain tension on theportions of suture extending between surface 212 of upper tissue piece202 and first throw 232, the user uses the rundown tool 100 to pushfirst throw 232 (received in V-shaped groove 106 in shaft 102) down thelengths of suture until the throw contacts tissue surface 212. (FIGS. 10and 11).

While holding throw 232 against tissue surface 212 with rundown tool100, device 20 is again dipped and rotated so as to disengage sutureends 200A and 200B from leading pegs 54 of group 52B. Support device 20is then moved away from tissue surface 214 to remove the slack in thesuture ends 200A and 200B created by releasing the suture ends from theleading pegs 54 of group 52A (FIG. 11a). Rundown tool 100 is thenextracted from cannula 206, and second throw 234 (FIGS. 7 and 12) ispositioned in V-shaped groove 106 in shaft 102 (FIG. 12). As this isdone, an upward force is preferably maintained on support device 20 soas to keep the length of suture extending between tissue surface 212 anddevice 20 taut. Such tautness will keep throw 232 from backing off fromtissue surface 212 in the event first throw 232 is a double turn throw.

Next the second throw 234 is run down the suture ends until it contactsfirst throw 232, following the procedure described above with respect tothe first throw, thereby forming a knot adjacent tissue surface 212(FIG. 13).

Thereafter, each of the remaining suture throws supported on supportdevice 20 is run down the suture ends until it contacts the immediatelypreceding throw, following the procedure described above with respect tothe first and second throws (FIG. 14). Finally, the ends of sutures 200Aand 200B are disengaged from support device 20 and are cut off adjacentthe last of the throws which was run down to the surgical site.

Alternative Embodiments

Referring to FIGS. 4 and 15, in place of frame 20 with its upstandingpegs 54 and 56, support device 20 may comprise an elongate block 300 ofmaterial, such as plastic, in which a plurality of passageways 302 areprovided. Passageways 302 are formed so as to define a plurality ofpairs of protrusions 356, each having a finger 358 which extends awayfrom the protrusion toward front surface 326 of the block. Passageways302 also define a pair of leading protrusions 354 which do not includefingers 358. Protrusions 354 are provided at the front end of block 300so as to be coextensive with front surface 326. A central passageway 338extends between the pairs of protrusions 356. The bottom of passageway338 is depressed below the bottom of protrusions 356.

Block 300 preferably includes a pair of front feet 350 which aresubstantially identical to feet 50 of frame 22. Thus, front feet 350 aresecured to the front of block 300, project outwardly from the block, andare inclined at about a 30° relative to front surface 326. Block 300also preferably includes a pair of rear legs 370 and 372 which aresubstantially identical to rear legs 70 and 72 of frame 22. Rear legsare pivotally attached to the rear end of block 300 so as to be movablebetween open and closed positions.

Suture ends 200A and 200B are threaded around protrusions 356 much likethe suture ends are threaded around pegs 54 and 56 of frame 22.Specifically, suture end 200A is positioned in passageway 302A at thefront of block 300 and suture end 200B is positioned in passageway 302B.Passageways 302A and 302B are formed between leading protrusions 354 andadjacent portions of block 300. After a double turn throw 332 is formed,the suture ends are wrapped around the front surfaces of the leadingpair protrusions 356, under their fingers 358, and around the backsurfaces 362 of protrusions 356. The portions of passageway 302 adjacentprotrusions 356 are sized to permit the suture ends to be wrapped aroundthe protrusions in this manner. Another throw 334 is formed using thesuture ends 200A and 200B, and the suture ends are then wrapped aroundthe second pair of protrusions 356, as described above with respect tothe first pair. Additional throws are formed, and the suture ends arewrapped around additional protrusions, following the procedure describedabove. Thus, unlike frame 22, with block 300 the suture ends leaddirectly from one pair of protrusions 356 to the next, rather than beingwrapped alternately around a leading pair of pegs 54 and a trailing pairof pegs 56.

Block 300 is used in much the same fashion as support device 20. Thus,after forming throws in the suture ends 200A and 200B and wrapping thesuture ends around protrusions 356, block 300 is dipped and rotated sothat the suture ends are removed from passageways 302A and 302B and arereceived in central passageway 338. Then, the first throw 332 is rundown the suture ends to the surgical site using rundown tool 100, asdescribed above with respect to throw 232 carried on support device 20.Subsequent suture throws are run down to the surgical site, as describedabove with respect to the discussion of the operation of support device20.

In certain circumstances suture ends 200A and 200B may extend away fromthe surgical site through a curved passageway, e.g., an esophagus,colon, etc. Rundown tool 100 cannot be satisfactorily employed undersuch circumstances because it is substantially rigid. To permit suturethrows to be run down a curved passageway, a flexible rundown tool 400is provided as part of the present invention, as illustrated in FIGS. 16and 17. Rundown tool 400 is made from a material which permits therundown tool to flex along its length, e.g., flexcable or flextube.

Except for the fact that the rundown tool 400 is made from a flexiblematerial, rundown tool 400 is similar to rundown tool 100, with theexception that the tool preferably comprises a spring guard 416 forensuring suture ends 200A and 200B remain positioned in the elongategrooves 408 of the rundown tool. Thus, elements 402, 404, 406, 408 and410 of rundown tool 400 are identical to elements 102, 104, 106, 108 and110 of rundown tool 100.

Spring guard 416 comprises curved arms 418 and 420. One end of arm 418is secured to shaft 402 adjacent front groove 406, and one end of arm420 is secured to shaft 402 adjacent front groove 406 and in diametricopposition to the one end of arm 418. Arm 418 curves around shaft 402 sothat its other end terminates adjacent, and covers, one of elongategrooves 408 in shaft 402. Arm 420 curves around shaft 402 so that itsother end terminates adjacent, and covers, the other one of elongategrooves 408. Arms 418 and 420 both press against shaft 402 with a springbias.

To use rundown tool 400 with spring guard 416, a suture throw ispositioned in front groove 406 and then the portions of suture ends 200Aand 200B extending rearwardly from groove 406 are urged between the freeends of arms 418 and 420 and shaft 402, thereby causing the arms to moveaway slightly from the shaft. The suture ends are then urged intoelongate grooves 408, with the result that arms 418 and 420 spring backinto contact with shaft 402. After the suture throw has been run down tothe surgical site, and the rundown tool 400 removed from the openingleading to the surgical site, the suture ends captivated by arms 418 and420 in elongate grooves 408 are removed by twisting shaft 402 slightlyand pulling each of the suture ends out from beneath arms 418 and 420.

Knot rundown tool 100 functions satisfactorily when constant downwardpressure is applied to the tool during the knot rundown procedure.However, under certain circumstances it is difficult or impossible tomaintain such pressure throughout the entire knot rundown procedure.Consequently, the knot or throw may slip out of the front groove 106 ofthe tool. Such disengagement of the knot from the rundown tool 100 maybe especially problematic when it occurs deep within the passagewayleading to the surgical site.

Referring to FIG. 18., to avoid this problem, a knot rundown tool 500 isprovided as part of the present invention. Tool 500 comprises anelongate shaft 502 (only the front end of which is shown in FIG. 18)having a axial bore 504 coupled with the front end of the shaft. Shaft502 also includes a groove 506 in the front end thereof for receiving asuture throw. Shaft 502 also includes a slot 508 extending through thecentral axis of the shaft perpendicular to the long axis of the shaft.Slot 508 is spaced rearwardly from front groove 506.

Rundown tool 500 also includes a sleeve 520 which surrounds the frontend of shaft 502 and is mounted for axial, reciprocal movement relativeto the front end of the shaft. Sleeve 520 has a hollow interior 522sized so that shaft 502 may be received therein with a freeaxially-sliding fit. Sleeve 520 includes a slot 524 which extendsthrough and perpendicular to the longitudinal axis of the sleeve and iscoupled with the front end of the sleeve.

Axial movement of sleeve 520 relative to the front end of shaft 502 islimited by pin 526 which is attached to the sleeve so as to extendthrough the hollow interior 522 of the sleeve perpendicular to the longaxis of the sleeve. Sleeve 520 is positioned relative to shaft 502 sothat pin 526 is received in slot 508 in shaft 502. As sleeve 520 ismoved axially relative to shaft 502, pin 526 will contact the top andbottom ends of slot 508, thereby preventing further movement of thesleeve relative to the shaft. The length of sleeve 520 and the placementof pin 526 in the sleeve are selected so that the front end of sleeve520 will project forwardly of the front end of shaft 502 when pin 526engages the front end of slot 508 in shaft 502, as shown in FIG. 18.When pin 526 engages the rear end of slot 508, the front end of shaft502 will project slightly beyond the front end of sleeve 520. Theorientation of pin 526 relative to slot 524 in sleeve 520 is selected toensure the slot remains aligned with groove 506 in shaft 502 as sleeve520 moves back and forth relative to the shaft 502.

Sleeve 520 additionally includes a spring 528 for urging pin 526, andsleeve 520 attached thereto, toward the front end of shaft 502. Spring528 is captivated between the end of bore 504 in shaft 502 and pin 526.Spring 502 has a spring force selected so that the spring urges the pin526 toward the front end of slot 508 with only a relatively moderatebias.

In connection with the following description of the operation of rundowntool 500, it is assumed the tool is initially in the unbiased conditionshown in FIG. 18. To use the tool 500, the latter is moved toward asuture throw 530 formed from suture ends 532 and 534 emanating from asurgical site so that the throw is received in slot 524 in sleeve 520.During this movement, tension is maintained on suture portions 536 and538. As tool 500 is moved toward throw 530 so as to cause the throw tomove more deeply into slot 524, tool 500 is manipulated so that thethrow is received in front groove 506 in shaft 502. When throw 530 isfully seated in front groove 506, suture portions 536 and 538 extendrearwardly away from the throw through slot 524.

After positioning the throw 530 in the front groove 506 of shaft 502,and while maintaining tension on suture portions 536 and 538, the shaftis urged toward the surgical site from which suture ends 532 and 534emanate. This movement of the shaft 502 causes throw 530 to run downsuture ends 532 and 534 toward the surgical site. As shaft 502 is urgedtoward the surgical site, sleeve 520 retracts (i.e. moves rearwardly)until pin 526 engages the rear end of slot 508. However, if during thecourse of the rundown procedure downward pressure is released from shaft502 while still maintaining tension on suture portions 536 and 538,spring 528 will urge sleeve 520 forwardly until pin 526 engages thefront end of slot 508. As a consequence of this forward movement ofsleeve 520, suture throw 530 is maintained in slot 524 in the sleeve.When downward pressure is again applied to the shaft 502 the throw willbe guided within the walls of slot 524 toward front groove 506 in shaft502. Thus, with rundown tool 500, downward pressure may be temporarilyreleased from shaft 502 without a resultant disengagement of the suturethrow 530 from the rundown tool. Additionally, pin 526 ensures sleeve520 remains rotationally aligned with shaft 502.

An important advantage of suture support devices 20 and 300 is that theypermit a single individual to run a number of suture throws down to asurgical site in quick succession. However, under certain circumstancesthe amount of time required to lace up the suture support devices 20 and300 with suture throws may be unacceptably large. In other cases, thesurgeon may desire to only run one or two throws down to the surgicalsite. To avoid the need to devote a significant amount of time to lacingup the suture support device, while at the same time enjoying thebenefit of a device for supporting at least one suture throw adjacentthe opening to a surgical site, a suture throw holder 600, asillustrated in FIG. 19, is provided as part of the present invention.

Holder 600 comprises a flat, elongate member 602 having front and rearends 604 and 606. Member 602 includes fingers 608 and 610 which areseparated by an aperture 612. Fingers 608 and 610 are attached to oneend of member 602 and terminate at the front end 604 of member 602. Thewidth of aperture 612 is selected so that fingers 608 and 610 are spacedabout 0.5" to 1.5" from one another, as measured between the innersurfaces of the fingers. Finger 608 includes pegs 620 and 622. Thelatter are attached to and project out from the outer surface of finger608. Finger 610 includes pegs 624 and 626 which are attached to andproject out from the outer surface of finger 610. Pegs 620 and 624 arepositioned opposite one another adjacent front end 604, and pegs 622 and626 are positioned opposite one another rearwardly of pegs 622 and 624.Each of the fingers 608 and 610 includes grooves 628 adjacent theirrespective pegs for receiving and directing suture, as discussed below.Grooves 628 also prevent the suture from being pinched between the innersurface of the fingers and the rundown tool. Holder 600 also includes aclamp 630 in the form of a flat plate positioned slightly above the topsurface 632 of member 602 so that suture may be wedged between the plateand the top surface, thereby securing the suture to the member.

Although holder 600 has been described as comprising two pairs of pegs(i.e. pegs 620 and 622 and pegs 624 and 626), it should be appreciatedthat the holder may be modified to include one, three or more pairs ofpegs.

In connection with the following description of the operation of suturethrow holder 600, reference should be made to FIGS. 19-25. For thepurpose of this description, it is assumed that a length of suture hasbeen passed through adjacent tissue pieces which are to be securedtogether, and the free ends 642 and 644 (FIG. 20) of the suture havebeen withdrawn from the surgical site. First, as illustrated in FIG. 20,a surgeon's knot 646 is formed adjacent the opening to the surgical siteusing suture ends 642 and 644. Then, member 602 is positioned so thatits front end 604 is located adjacent the surgeon's knot 646, as shownin FIGS. 20 and 21.

Next, suture portions 648 and 650, which extend away from the surgeon'sknot 646, are wrapped around front pegs 620 and 624, respectively, asillustrated in FIGS. 22 and 23. Grooves 628 formed in fingers 608 and610 receive and direct suture portions 648 and 650 toward pegs 620 and624. Thereafter, a single-turn throw 652 is formed in the free ends ofsuture portions 648 and 650 extending rearwardly from front pegs 620 and624. Finally, the lacing procedure is completed by wrapping the freeends of suture portions 648 and 650 extending rearwardly from throw 652around rear pegs 622 and 626, and then securing the free ends extendingrearwardly from the rear pegs at clamp 630. The grooves 628 in fingers608 and 610 adjacent rear pegs 622 and 626 receive and direct the sutureportions toward the rear pegs.

The above-described lacing procedure is typically accomplished with oneperson holding the rear end of member 602 while a second person formsthe surgeon's knot 646 and throw 652 and wraps the suture portionsaround the pegs 620-626. However, a single person may also perform thelacing procedure while the member 602 rests on the patient adjacent theopening to the surgical site.

To run the surgeon's knot 646 down to the surgical site, member 602 ismanipulated so as to apply tension to suture ends 642 and 644 and sutureportions 648 and 650, as shown in FIGS. 24 and 25. Next, a knot rundowntool 670 having a front, knot-receiving groove 672 is provided. Theabove-described knot rundown tools 100, 400 and 500, and knot rundowntools 700 (FIG. 26) and 800 (FIGS. 27 and 28) described hereinafter, maybe satisfactorily employed as tool 670. Rundown tool 670 is thenpositioned so that the surgeon's knot 646 is received in its frontgroove 672. While maintaining tension on suture ends 642 and 644 andsuture portions 648 and 650, rundown tool 670 is urged downwardly towardthe the surgical site. As a consequence of this movement, the surgeon'sknot 646 is run down suture ends 642 and 644 to the surgical site.

Next, to run throw 652 down to the surgical site, suture portions 648and 650 are unwrapped from front pegs 620 and 624. Rundown tool 670 isthen positioned so that the throw 652 is received in groove 672. Whilemaintaining tension on suture ends 642 and 644 and suture portions 648and 650, rundown tool 670 is urged downwardly toward the the surgicalsite. As a consequence of this movement, the throw 652 is run downsuture ends 642 and 644 to the surgical site, typically so as to contactsurgeon's knot 646. If required, additional knots or throws may be rundown to the surgical site by repeating the above- described lacing andrundown procedures.

In yet another embodiment of the knot rundown tool, which is identifiedat 700 in FIG. 26, rundown tool 700 includes an elongate tube 702 havingfront and rear ends 704 and 706, and a hollow interior 708. Tube 702comprises a deep groove 710 in its front end 704, which groove is sizedto receive a knot or throw formed using two ends of suture.

Tool 700 also includes a handle 720 having front and back walls 722 and724 and a hollow interior 726. Handle 720 includes a front bore 728 infront wall 722 and a rear bore 730 in rear wall 724. The diameter ofbores 728 and 730 is about equal to the inside diameter of tube 702, andbores 728 and 730 are aligned with one another. Handle 720 is attachedto rear end 706 of tube 702 so that the interior 708 of the tube iscoupled with bore 728 in front wall 722 of the handle.

Tool 700 further includes an elongate rod 740 which is disposed inhollow interior 708 of tube 702. Rod 740 comprises front and rear ends742 and 744, and is sized so as to slide freely along its axis ininterior 708. Rod 740 also includes a groove 746 in its front end 742,which groove is sized to receive a knot or throw formed with two ends ofsuture. Rod 740 is sized so that when its front end 742 is adjacent thefront end 704 of tube 702, as shown in FIG. 26, the rear end 744 of thetube is flush or nearly flush with the rear wall 724 of the handle, asalso shown in FIG. 26.

Tool 700 additionally comprises a radially-projecting flange 750 whichis attached to rod 740 at a location spaced a distance from its rear end744 which is roughly equal to the axial depth of groove 710 in tube 702.Tool 700 also includes a coil spring 752 which surrounds rod 740 and iscaptivated between flange 750 and the inside surface of front wall 722of handle 720. When rod 740 is urged forward, as shown in FIG. 26, abias is applied to spring 752. When rod 740 is released, the bias inspring 752 urges flange 750, and rod 740 attached thereto, rearwardlyuntil the flange contacts the inside surface of rear wall 724 of handle720. In this unbiased state, the front groove 746 of rod 740 ispositioned just rearwardly of the base of groove 710 in tube 702, andthe rear end 744 of the rod projects outwardly past rear wall 724 ofhandle 720.

In connection with the following description of the operation of rundowntool 700, it is assumed the tool is initially in the unbiased statedescribed above. To use the tool 700, the latter is moved toward asuture throw formed from suture ends emanating from a surgical site sothat the throw is received in groove 710 in tube 702. After positioningthe suture throw in the front groove 710 of tube 702, and whilemaintaining tension on suture ends emanating from the surgical site,tool 700 is urged toward the surgical site. This movement of the tool700 causes the throw to run down the suture ends toward the surgicalsite. Once the throw is positioned at or adjacent the surgical site, rod740 is urged forward by pressing on its rear end 744. As rod 740 movesforward relative to tube 702, the suture throw in groove 710 of tube 702is picked up in groove 746 in rod 740 and carried forward. This forwardmovement of the throw tightens the throw and disengages the throw fromthe tube 702.

Another embodiment of the knot rundown tool 800 is shown in FIGS. 27 and28. A front end 804 of a shaft 802 includes a frusto-conical depression806. The diameter of depression 806 is less than the outside diameter ofthe front end 804 of shaft 802, whereby an annular land 810 extendsaround the peripheral portion of the front end of the shaft.

Shaft 802 additionally comprises a chamber or cavity 820 having parallelside walls which extend parallel to the axis of the shaft. Cavity 820includes diametically-opposed grooves 822 and 824 which intersectannular land 810. Grooves 822 and 824 extend rearwardly from annularland 810, initially parallel to the longitudinal axis of shaft 802, andthen as they continue rearwardly the grooves penetrate more deeply intoshaft 802 until they eventually meet at location 826 (FIG. 28). Cavity820 further includes diametrically opposed grooves 828 and 830 whichtaper inwardly towards the central axis of shaft 802 as they extendtoward the front end 804 of the shaft. Grooves 828 and 830 eventuallymeet at point 832 (FIG. 28). As such, the portion of cavity 820 betweenpositions 826 and 832 extends entirely through the shaft, perpendicularto the axis of the shaft.

Shaft 802 additionally comprises a slot 840 which extends transversely,typically perpendicular to, the longitudinal axis of shaft 802. Slot 840intersects the opening in cavity 820 between portions 826 and 832 andhas a width just slightly greater than the outside diameter of thesuture material to be used with rundown tool 800.

To use tool 800, the latter is moved toward a surgeon's knot (orsingle-turn throw) 850 formed using suture ends 852 and 854 emanatingfrom a surgical site so that the surgeon's knot is received infrusto-conical depression 806 and the front end 804 of the shaft. Shaft802 is manipulated so that suture portions 856 and 858 extendingrearwardly from surgeon's knot 850 are received in front grooves 824 and822 respectively. Suture portion 858 is then inserted into slot 840 soas to initially be received in the portion of cavity 820 betweenportions 826 and 832. Then, suture portion 858 is tensioned so as toextend along the sloping portions of front groove 822 and rear groove830. Thereafter, suture portions 856 and 858 are lead rearwardly fromthe front end 804 of shaft 802.

Next, while maintaining tension on suture ends 852 and 854 emanatingfrom the surgical site and suture portions 856 and 858 extendingrearwardly away from the front end 804 of shaft 802, tool 800 is urgeddownwardly toward the surgical site. This movement of the tool 800causes the surgeon's knot 850 to run down the suture ends 852 and 854toward the surgical site. Once the surgeon's knot 850 is positioned ator adjacent to the surgical site, shaft 802 is pulled rearwardly awayfrom the surgical site. During this rearward movement, suture portion858 is drawn through cavity 820. If desired, tool 800 may be movedrearwardly until the free end of suture portion 858 passes through andout of cavity 820. Alternatively, the rundown tool may be extractedrearwardly a distance such that the tool is no longer positioned in theopening leading to the surgical site. Thereafter, suture portion 858 maybe extracted from shaft 802 via slot 840, thereby eliminating the needto run the entire length of suture portion 858 through cavity 820.

The suture holder, rundown tool and cutter system embodying the presentinvention is characterized by a rundown tool of the type hereinbeforedescribed in combination with a cutter, means being provided for guidingthe cutter to a position for severing the suture ends adjacent the knot.A specific embodiment of a rundown tool and cutter system embodying thepresent invention is denoted by the reference character 900 in FIGS. 29and 30. Rundown tool and cutter system 900 includes a suture knotrundown tool 902 and a cutter assembly 904. Suture knot rundown tool 902includes a shaft 906 and a handle 907 that is attached to the shaft at aback end of the tool. In one embodiment, shaft 906 has a frusto-conicaldepression 908 at a front end thereof. The diameter of depression 908 isless than the outside diameter of shaft 906, whereby an annular land 910extends around the peripheral portion of the front end of the shaft.

Shaft 906 additionally comprises a central bore 920 having parallel sidewalls which extend parallel to the axis of the shaft.Diametrically-opposed grooves 922 and 924 a front end of rundown tool902 intersect annular land 910. Grooves 922 and 924 extend rearwardlyfrom annular land 910, parallel to the longitudinal axis of shaft 906.

Shaft 906 additionally comprises a pair of longitudinal,diametrically-opposed slots 928 and 930, and a transverse slot 940.Slots 928 and 930 are parallel to the longitudinal axis of shaft 906 andslot 940 is perpendicular to the longitudinal axis of shaft 906. Slot940 intersects or communicates with both slots 928 and 930. The width ofslots 928, 930 and 940 are just slightly greater than the outsidediameter of the suture material to be used with rundown tool 900.Central bore 920, which extends the length of tool 900, defines aguideway for cutter assembly 904.

Referring now to FIG. 32, it will be seen that cutter assembly 904includes an elongated shaft 952 having a sharp cutting blade 954 at afront end. A handle 956 is attached to a back end of shaft 952. Shaft952 is sized and shaped to be slidably received in central bore 920. Thelength of shaft 952 is such that blade 954 will be adjacent to grooves922 and 924 without extending beyond the front edge of rundown tool 902when rundown tool handle 907 and cutter handle 956 are together.

To use tool 900, knot rundown tool 902 is moved toward a knot (orsingle-turn throw) 980 (FIG. 33) formed using suture ends 982 and 984emanating from a surgical site so that the knot is received in the frontend of the shaft 906. Shaft 906 is manipulated so that suture portions986 and 988 extending rearwardly from the knot 980 are received in frontgrooves 924 and 922, respectively. Suture portions 986 and 988 are theninserted into slot 940 so as to initially be received in the portion ofbore 920. Then, suture portion 988 is tensioned so as to extend alongthe front slots 928 and 930. Thereafter, suture portions 986 and 988 arelead rearwardly from the front end of shaft 906.

Next, while maintaining tension on suture ends 982 and 984 emanatingfrom the surgical site and suture portions 986 and 988 extendingrearwardly away from the front end of shaft 906, tool 902 is urgeddownwardly toward the surgical site. This movement of the tool 902causes the knot 980 to run down the suture ends 982 and 984 toward thesurgical site. The procedure continues until the surgeon has made a knotwith the desired number of throws. Then, cutter assembly 904 is insertedinto central bore 920 and pushed downwardly in the central bore whichlies in a path that intersects suture ends 986 and 988 above the knot.Blade 954 blindly severs suture ends 986 and 988 at substantially thesame length every time adjacent the knot. Suture ends 986 and 988 areblindly severed closer to the knot at substantially equal lengths whenthe suture ends pass out the same side of tool 902 as shown in FIG. 34.Once suture ends 986 and 988 have been severed tool 902 and cutter 904are extracted from the surgical site.

An important advantage of the present invention is that it permits anumber of throw (formed using suture ends extending from a remotesurgical site) to be laced onto a holding device at a location remotefrom the surgical site, and then quickly and easily run down the sutureends to the surgical site so as to form a multiple throw knot at thesurgical site, substantially without damaging the tissue in which thesuture is positioned. Then, while the knot rundown tool 902 is in place,the suture ends are blindly cut at substantially equal lengths everytime adjacent the knot.

Since certain changes may be made in the above disclosure withoutdeparting from the scope of the invention herein involved, it isintended that all matter contained in the above description and shown inthe accompanying drawings be construed in an illustrative and not in alimiting sense.

What is claimed is:
 1. A suture throw holder, rundown tool and cuttersystem for running one or more throws down loose ends of a sutureextending from a surgical site, and for severing the loose ends of thesuture, said system comprising:(a) support means for releasablysupporting adjacent a surgical site at least one throw formed using twoends of suture extending from the surgical site; (b) rundown tool meansfor transferring said at least one throw from said support means andrunning said at least one throw down said two ends of the suture to saidsurgical site to form a knot; and (c) cutter means for cutting thesuture ends adjacent said knot; (d) said rundown tool means having guidemeans for guiding said cutter means along a path that intersects thesuture ends adjacent said knot.
 2. A system according to claim 1 whereinsaid rundown tool means comprises an elongate shaft having a front end,said front end including groove means sized to receive said at least onethrow and wherein said guide means is a longitudinally extending boreformed in said elongate shaft, said bore extending longitudially thelength of said rundown means.
 3. A system according to claim 2 whereinsaid shaft includes longitudinal slot means and transverse slot means,said transverse slot means communicating with said longitudinal slotmeans.
 4. A system according to claim 3 wherein said longitudinal slotmeans includes diametrically-opposed slots, said slots communicatingwith said transverse slot means.
 5. A method of running throws formedusing two loose ends of suture extending from a tissue surface in asurgical site down the loose ends of the suture to the tissue the looseends of the suture to substantially the same length every time adjacentthe knot, the method comprising the following steps:(a) providing asuture throw holder and rundown tool device comprising:(i) support meanscomprising a frame having a leasing edge, a trailing edge, a clampattached to said trailing edge, and plurality of protrusions attached tosaid frame in adjacent groups, each of said groups of protrusionscomprising a first pair of protrusions which lie on a leading plane anda second pair of protrusions which lie on a trailing plane, wherein saidleading plane is closer to said leading edge of said frame than saidtrailing plane, and further wherein the protrusions of said first pairare positioned farther apart than the protrusions of said second pairand each of said plurality of protrusions comprises an inner surface andan outer surface; (ii) leg means attached to said frame for supportingsaid frame in a predetermined orientation relative to said surgicalsite; (iii) said rundown tool device including a elongate shaft having afront end, said front end including a first groove sized to receive athrow formed using two loose ends of suture extending from a surgicalsite, said first groove having a bottom portion; and a longitudinallyextending bore formed in said shaft, said bore extending the entirelength of said rundown device; and (iv) cutter means slidably receivedin said bore; (b) positioning said support means adjacent an opening intissue leading to a surgical site so that said leading edge of saidsupport means is positioned adjacent said opening, wherein said surgicalsite comprises a tissue surface and two lengths of suture extendingthrough said tissue surface and away from said surgical site; (c) tyinga throw in said two lengths of suture and releasably attaching saidthrow to a first one of said groups of protrusions, which first one ofsaid groups is positioned closest to said leading edge of said supportmeans, so that the portions of said lengths of suture extending fromsaid surgical site to said throw are wrapped around said first pair ofprotrusions so as to engage said outer surfaces thereof and so that theportions of said lengths of suture extending away from said throw towarda second one of said groups of protrusions are wrapped around saidsecond pair of protrusions so as to engage said inner surfaces thereof;(d) tensioning the ends of said lengths of suture extending away fromsaid throw toward said second one of said groups of protrusions; (e)pulling said support means away from said opening so as to substantiallyeliminate any slack in those portions of said lengths of sutureextending between said tissue surface in said surgical site and saidfirst pair of protrusions around which said lengths of suture arewrapped; (f) manipulating said support means so as to disengage saidlengths of suture from said first pair of protrusions; (g) manipulatingsaid shaft so that said throw is received in, and engages the bottomportion of, said first groove; (h) urging said shaft toward said tissuesurface, while maintaining engagement of said throw with said bottomportion of said firs groove, so as to cause said throw to run down saidlengths of suture until said throw is positioned adjacent said tissuesurface; (i) forming a knot at the surgical site; and (j) guiding saidcutter means down said bore and blindly cutting the suture ends adjacentsaid knot.
 6. A method as claimed in claim 5 wherein the suture ends arecut at substantially equal lengths.